Overwhelmed: How Kenya’s overzealous patient referral system is clogging the pipe

A patient lies on the floor at the mental health unit of Kisumu District Hospital in March 2016. At the time, the hospital was taking care of 50 patients, against a bed capacity of 20. PHOTO| FILE| NATION MEDIA GROUP

The winding corridors of Coast General Hospital lead to wards that are perennially congested, at Kenyatta National Hospitals patients share beds, while at Jaramogi Oginga Odinga Teaching and Referral Hospital the floor sometimes is the only available space for in-patients.

This sorry state of affairs is replicated in all the major referral hospitals in the country. Actually, not just the referral facilities, but any that has an in-patient wing.

It has become so common that it has become accepted, almost expected. But it shouldn’t, because this mess, according to hospital administrators, is created by a sick referral system that uses Kenya’s big hospitals as dumping grounds for lower level facilities. The result is a health system that is clogged at the top, leading to poor services, overcrowded facilities, overworked medical staff, and, as a result, medical malpractices, such as misdiagnosis.

With devolution, many hoped that the expansion and equipping of county hospitals would ease this congestion, but it seems to have made it worse as ambulances wail through traffic every day as they rush referred patients to the major hospitals in or around the counties.

The most affected sections, our investigations show, are orthopaedic, surgery and emergency wards, and at KNH the deputy director of planning and strategy, Mr Job Makanga, says the county’s lower level facilities are responsible for the bulk of referrals, at 46 per cent. Kiambu County follows in the list of shame with 13 per cent, followed by Machakos (6.3 per cent), Kajiado (5.6 per cent) and Murang’a (4.3 per cent).

The leading causes for admissions at the hospital are head injuries (7.2 per cent), other fractures (5.9 per cent), abdominal appendicitis (4.2 per cent), kidney (3.8 per cent) and cancers (3.4 per cent).

Mr Makanga says the nation’s biggest and busiest referral hospital handles such a high number of referral cases because Nairobi County’s devolved health system is “broken down”.

“For instance, were Pumwani, which handles deliveries of babies, and Mbagathi, which should take care of infectious diseases, in order, most cases would be handled there instead of causing congestion in our maternity and general wards,” he says.

But the problem is not just about whether these lower hospitals have the capacity to treat, but also how they are viewed by most Kenyans. Trust, it turns out, is a major driver of where patients eventually end up.


Mr Makanga says KNH, which handles around 900,000 patients a year, or about 2,400 a day, could do a much better job at handling the more complicated medical cases it was designed to take care of, but it is often overwhelmed by the pilgrimage from the counties.

“Every day we have between 2,000 and 2,400 patients spending the night in the hospital, making efficiency in patient management an uphill task,” says Mr Makanga. “In addition, some of the patients are abandoned by their families, making recovery of the monies spent in purchasing essential supplies for them like oxygen, cotton wool, water and glucose an impossible undertaking.

And since hospitals and doctors are bound by the law to take care of the sick — Article 43 criminalises the denial of healthcare to Kenyans who visit health facilities — these hospitals end up admitting and taking care of patients they ordinarily should not.

Kenyatta National Hospital spends about Sh700 million a year to pay for the medical costs of financially challenged patients, as well as feed them and accommodate them. The money, says Mr Makanga, comes from the cost-sharing funds collected from patients.

“We received Sh220 million for construction of a cancer wing but are unable to channel more funds into this or other projects because of outstanding debts and national government budget constraints. This further complicates our financial position and prevents the facility from spending money allocated for development on capital ventures, like expanding wards,” says Mr Makanga.

And ward capacity, for many referral hospitals, remains a thorn in the flesh. In a previous interview with this newspaper, Coast General Hospital chief administrator, Dr Iqbal Khandwalla, said the facility receives between 700 and 800 patients daily, against a bed capacity of 700. The hospital serves the wider coastal region, from Taita-Taveta through Kilifi and Kwale, all the way to Lamu and Tana River.

Speaking shortly after her appointment in November 2017, the county executive in charge of health, Ms Hazel Koitaba, lamented the congestion, saying “there is need to improve the existing dispensaries and clinics to reduce the load of patients”.

In Isiolo, the county deputy governor and health CEC, Dr Abdi Issa, said the region had a shortage of doctors occasioned by small health budget allocations, a challenge it shares with Lamu County.

“We have 30 doctors in Isiolo, 17 of whom are in training, and a shortage of 54 nurses in an area which is 20,000 square kilometres,” said Dr Issa. “The trainees have been in the learning programme for four years, which is an artificially created shortage that leaves us in limbo as we are stuck between sourcing for new doctors and paying salaries for the 17 as fully qualified professionals.”


When HealthyNation visited Dr Juliana Otieno, the chief executive officer at Jaramogi Oginga Odinga Teaching and Referral Hospital, and Dr Enock Ondari at Kisii Teaching and Referral Hospital, last week, they admitted that most patients being taken care of at the facilities were suffering from minor ailments that could be handled at lower level facilities.

The administrators acknowledged that the referral system in the country is a major national problem that must be sorted out.

To address this challenge, Dr Otieno said Kenya should go the Tanzania and Rwanda way, where specific conditions are handled in specific hospitals.

“We need to have referral guidelines in place, where patients with only severe cases which cannot be handled by health centres are brought in,” said Dr Otieno. “Such minor ailments as common colds should not be handled by referral facilities, as is currently the case.”

She challenged sub-county hospitals to serve patients better, avoid duplicating treatment, and improve staffing. Such hospitals, she added, should create awareness on the services they offer. “These are not just buildings, but hospitals that offer services,” she said, “and these services should be known to all Kenyans.”

The medic said Kenya should promote the ethos of primary treatment, whereby immunisation and minor ailments are handled by dispensaries and health centres to give room for referral hospitals to handle severe cases.

And Dr Otieno has every reason to feel overwhelmed. Consider this: between January and December last year, Jaramogi Oginga Odinga Teaching and Referral Hospital admitted over 600 patients, mostly mothers and children.

That is a huge figure, but it is an improvement from 2016, when the hospital handled 1,828 referrals, with the bulk of patients coming from neighbouring counties like Vihiga, Siaya, Kakamega and Homa Bay.

“I am wondering why we have sub-county hospitals which cannot handle minor cases like obstructed labour and pre- or post-delivery related bleeding in mothers. These should not congest referral hospitals,” Dr Otieno says, adding that mothers at times lose lives that could have been saved in the health centres.

“Tuning away a mother or an accident victim can be very challenging but if the mothers can be cared for at the sub-county hospitals, then the beds can be occupied by mothers in need of specialised care.” she said.

The Ear, Nose and Throat ward at Jaramogi Oginga Odinga Teaching and Referral Hospital has only two rooms, so patients come in on Sundays, get surgery on Mondays, and are discharged the next day to create space for other admissions.

Matters are not any different at the Kisii Teaching and Referral Hospital (KTRH), but the chief executive officer, Dr Enock Ondari, says this is a national problem that has run out of control, probably because of the perception that bigger hospitals are better staffed and better equipped than lower facilities.

“It is true that they are well equipped, but the same applies to the smaller hospitals, which are well-equipped to handle minor cases,” says Dr Ondari.

KTRH admits patients referred from all the sub-district hospitals in the county as well as from the surrounding counties of Narok, Homa Bay, Nyamira and Migori.

“We have 450 beds but average a 105 per cent occupancy, meaning some beds have to accommodate two patients,” says Dr Ondari.

The hospital gets nine to ten referrals a day — 200 a month, 2,400 a year. As a result, and just like Jaramogi, the children’s, surgical, and medical wards at KTRH are perennially congested.